87-1679 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (WJJ FE 1601 E. HAZE l ON AVE., STOCKTON, CA Telephone (209) 466-6781 ND to PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED �. (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size 7� S PM t3wner's Name Address _ Y' Phone 9 9— MV0T LL- Contractor dress (' �i �� License No:- -4ir `OV Phone 'L� Z Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑' +� _ .„�.,�..,,. .._-_SYSTEM.REPAIR.0.—.—OTHER �. -: -----; ..�.._�PUMP 1 NSTALLATION,.❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROO�LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial 10 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l i ❑ Public 10 Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work bone ❑ Type of Pump H.P. State Work Done r Well Destruction ❑ I Well Diameter Sealing Material (top 501 l }Depth 'Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDIT}@N L❑ DESTRUCTIO C1 (No septic system permitted if public sewer is J a Mable within 200 feet.) r } Installation will serve: Residence_ Commercial_ Other �� Number of living units: Number of bedrooms Character of soil,to.a depth of 3 feet: ---- – - -{ Water table depth SEPTIC TANK ' ❑ Type/MfgCapacity l No. Compartments E_1PKG. TREATMENT,PLT. s r Method of Disposal 5 e �LL Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines s Total length/size + FILTER BED E5 Distance to nearest: Well Foundation.-1 !Property Line- t SEEPAGE PITS ❑ Depth Size t Number I r ' SUMPS ❑ Distance toinearest: Well Foundation q�q Property Line DISPOSAL PONDS ❑ I. ' hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I Homeowner or licensed agent's signature certifies the following: "I cert!N that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's'oompensation laws of California."Contractor's hiring or sub-contracting signature x certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion laws of California." 1 , The applican must call fo all required inspections. Complete drawing on reverse side' % I Title: ' Date: �� Signed s , I � ' ,j- �`�FOEI��RTMENT'USENLY Application.Accepted by _ Q — Date Area Pit or Grout Inspection by Date Final Inspection by r Additi al Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M Applicant='Return all copies to: Environmental Health Permit/Service&.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 l IFEE NFO AMOUNT DUE AMOUNT,REMITTED CASt� RECEIVED BY DATE PERMITONO�. + EH 13-24(REV,1/851 EH 14-28 t i